Trauma team and organization of the initial resuscitation

The resuscitation of severely injured patients usually involves many personnel, and too often takes place in an environment of anxiety and confusion. A well-planned and organized approach to such patients is fundamental to optimal management. Resuscitation implies a coordinated group of actions performed to secure the airway, support breathing and restore circulation. Survival after severe injury depends on promptly re-establishing adequate tissue oxygenation. Hence, critical time limitations apply to the successful performance of the elements of resuscitation. There is thus a need to assure that the personnel and equipment needed for resuscitation are present and utilized in an optimal fashion. Achieving this goal is assisted by appropriate pre-planning and coordination among personnel caring for the injured patient in the field, in the emergency department and elsewhere in the hospital. Such pre-planning and coordination involve equipment and supplies in the emergency area. However, more than anything else, they involve the organization of personnel as addressed by the concept of the trauma team.

Both the American College of Surgeons' Committee on Trauma and the British Trauma Society have emphasized the functioning of the trauma team as a critical element in assuring the quality of trauma treatment in their countries (/7, 54). The exact composition of the trauma team varies with local rules, conditions and staffing. However, a key element is organization, with pre-assigned roles for members of the trauma team and protocols to assure rapid assembly and efficient operation of the trauma team.

At hospitals in high-income countries, members of a trauma team typically include the following personnel (17, 68):

— airway control (may be a surgeon, anaesthetist, emergency physician or other);

— recorder (usually a nurse; the recorder sometimes takes on some of the duties of the above-mentioned primary nurse);

— airway assistant (respiratory therapist, nurse or other suitable person with the skills needed);

— laboratory technician.

Further details on the roles of each of these team members are presented in Annex 2.

In the above scenario, if there is an abundance of personnel, another doctor may assume the role of primary resuscitator. This person then undertakes the primary and secondary survey, while the team leader has less direct hands-on involvement, but still takes on the duties of coordination, review of data, and formulation of definitive plan. In cases where there is an abundance of nurses, one nurse may take the role of primary nurse. This nurse performs procedures and obtains vital signs as mentioned above, while a second nurse undertakes the documentation and assists the primary nurse as needed.

Some authors from middle-income countries have reported modifications of trauma team set-up to suit local staffing. For example, in South Africa there are no respiratory therapists. Hence, the tasks of the airway assistant in the schema above are handled by nurses with the necessary training in ventilator management. Likewise, in Mexico, the lack of respiratory therapists and shortages of laboratory technicians have lead to modifications in the trauma team whereby additional nurses are utilized to perform these functions. In particular, the nurse performing the recorder function is also in charge of making calls and processing orders for laboratory work, X-rays and other services. This person also maintains order in the resuscitation room and is in charge of not permitting the presence of any more people than necessary. One of the extra nurses also assists with airway procedures, locating all the equipment needed and administering whatever medications might be needed as an adjunct to intubation. Finally, paramedics/emergency medical technicians (EMTs) are routinely stationed in the emergency department as a way of promoting their training and experience. One or more such paramedics/EMTs take part in the trauma team. They assist with a variety of the above duties, and in particular assist with the transport of patients to other hospital departments (69).

Almost all of the above experience has been gained either in high-income or middle-income countries, and usually from larger urban trauma centres. There is a need to address the adaptation of the trauma team concept to smaller hospitals, especially those primarily staffed by general practitioners. At these hospitals, there are smaller numbers of professional staff of all types. Typically, there is only one nurse present in the emergency department at night; a doctor on call from home; limited telecommunications with pre-hospital care facilities (if any element of pre-hospital care even exists); limited telecommunications within the hospital; minimal equipment and supplies; and often limited capabilities for emergency referral. None the less, improvements in planning for trauma resuscitation are expected to be beneficial.

In this regard, the experience from the Trauma Team Training course in Uganda (TTT, described in section 6.1) is interesting. This course emphasized effective teamwork in the setting of rural, GP-staffed African hospitals. In a qualitative assessment of the effectiveness of this course, key informant interviews were con ducted with course participants, casualty department staff with whom the course participants subsequently worked, hospital administrators and patients. The trauma team training appeared to have improved practical skills and led to more systematic trauma team functioning. It was not yet possible to evaluate an effect on actual outcome (personal communication, Olive Kobusingye, Ronald Lett). Given the promising results from this approach, further expansion and evaluation of the possible role of trauma team organization in rural, GP hospitals is warranted.

Organized trauma teams have been shown to improve the process and outcome of trauma care, primarily in high-income countries. Driscoll et al. examined trauma resuscitations (70). In the presence of an organized trauma team, resuscitation time was reduced by 54%. This was felt to be due to precise task allocation, larger trauma teams and the adoption of simultaneous rather than sequential resuscitation. The involvement of an experienced senior trauma team leader, who was not actively involved in the physical aspects of resuscitation, was found to help to shorten resuscitation times. Likewise, consistent positioning of all trauma team members promoted smooth personnel interaction and efficient completion of assigned tasks.Vernon et al. looked at the effectiveness of improvements in a multidisciplinary paediatric trauma team (71). The improved organization resulted in shorter times to CT scanning for head-injured patients, shorter times to the operating theatre for emergency procedures, and decreased total times in the emergency department. Another British study reported that the new establishment of trauma teams at a district hospital had resulted in a reduction in preventable deaths. This study emphasized that such establishment of new trauma teams could be accomplished at virtually no cost, included ATLS training (see section 6.1) as a necessary component and relied on adequate recording of information to allow ongoing audit of trauma team function (72).

Several other studies have looked at specific elements of the functioning of the trauma team. Hoff et al. (68) showed that an identified team leader (command-physician) improved trauma resuscitation. Compared with trauma resuscitations without a designated team leader, those resuscitations which had a team leader had an increased proportion of completed secondary surveys and formulated definitive plans. Likewise, the presence of a designated team leader improved the orderliness of resuscitations and adherence to ATLS guidelines. A similar study from Australia reviewed fifty trauma resuscitations. In this, the function of the team leader was analyzed using a team leader score. This demonstrated that the major shortcomings in trauma resuscitations in their hospital related to interpersonal communications with other members of the team and adequacy of documentation (73).

There has been some preliminary evidence for the utility of the organization of trauma teams in several developing countries (66, 74, 75). For example, in the aforementioned development of the system for trauma management in the region of Khon Kaen, Thailand, improvements in the trauma team in the emergency department constituted a critical component of efforts to improve trauma care at that hospital. These improvements included increasing senior surgical involvement in the emergency department during peak hours, and increased communications between the trauma team in the emergency department and other personnel elsewhere in the hospital. As previously noted, such changes, along with other changes in the functioning of the hospital, were associated with improved process and decreased mortality of trauma patients (66).

Likewise, in Turkey, the new establishment of a trauma team at an urban trauma centre improved on previously haphazard care. The mortality of patients with injuries severe enough to warrant admission to the general surgery service decreased from 33% to 23%. There was a decrease in unexpected deaths. These improvements were felt to be particularly due to improved resuscitation of patients in shock and improved airway management, especially advanced airway management including endotracheal intubation (76).

The above examples indicate that improvements in trauma team organization can be a cost-effective way of facilitating the implementation of the Guidelines for essential trauma care. Finally, physical resources for improved trauma resuscitation also need to be addressed. These include such issues as the configuration of the trauma resuscitation area and the immediate availability of equipment. The physical space should be sufficient to hold a patient, the necessary personnel and the equipment. It should be well lit and access should be limited, in order to prevent non-essential personnel from disrupting resuscitation activities. Instruments and equipment should be available to perform emergency procedures such as endotracheal intubation, cricothryroidotomy, chest tube insertion and peritoneal lavage. Pre-assembled materials for these procedures should be kept immediately available in the resuscitation area. Likewise, emergency medications should be immediately available. These include drugs needed for paralysis and intubation, analgesics, medications for cardiac resuscitation and antibiotics. To the extent that infrastructure permits, the resuscitation area should include telephones or other means of communication with personnel in the rest of the hospital, such as staff who are on call but not stationed in the emergency area (17).

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